Health Center(SLHC) Enrollment Packet

Maysville School – Linked

Health Center(SLHC) Enrollment Packet

PLEASE COMPLETE AND SIGN ALL PAGES. CALL 740-891-9000FOR HELP WITH THESE FORMS.

Patient’s Name: DOB: Sex: M _____ F ______

Patient’s Social Security #: Patient School ID #:

Patient’s Current School: Patient’s Current Grade:

PRIMARY CARE SERVICES:

YES, I consent for my child to receiveNON-EMERGENCYMEDICAL CAREat the School Linked Health Center (SLHC) including routine well child care* (includes work, daycare and sports physicals), appropriate immunizations, and treatment for illness or injury including over the counter, prescription medications and confidential care.**

(*Note: well child care includes vision and hearing screenings, urine and blood tests, immunizations as needed and an external genital exam only when necessary).
(**Note: MVHC will always encourage patients to discuss health issues with their trusted guardians. However, per State law, MVHC providers cannot discuss certain topics if the patient has requested confidentiality. These topics include mental health, substance abuse and sexual health.)

NO, I do not wish for my child to receive NON-EMERGENCYMEDICAL CARE at the SLHC.

DENTAL SERVICES:

YES, I consent for my child to receive DENTAL SERVICES at the SLHC including preventive care, dental examinations,
x-rays, fillings, local anesthesia, tooth removal, and root canals if needed. Sealants and other preventable procedures will be provided at school. (Treatment plan will be approved with parents/guardians prior to starting).

NO, I do not wish for my child to receive DENTAL SERVICES at the SLHC.

VISION SERVICES:

YES, I consent for my child to receive VISION SERVICES at the SLHC, which may include comprehensive eye examinations (including dilation), vision therapy, and the fitting and dispensing of vision correction.

NO, I do not wish for my child to receive VISION SERVICES at the SLHC.

TRANSPORTATION:

YES, I consent for my child to be TRANSPORTED to and from medical, dental or vision services at the SLHC. I, the parent or guardian of above named student, release MVHC, its Board Members, employees, authorized agents, and representatives as well as the Maysville School District, its Board Members, administrators, employees, authorized agents, and representatives from all liability related to personal injury or damage resulting from the transportation of my student to and from health services.

NO, I do not wish for my child to be TRANSPORTED to and from the SLHC. I understand that I, therefore, am responsible for transporting my child to all SLHC appointments.

Please turn to the back of the page for to sign for consent

By signing this consent, I agree to the terms and conditions regarding the PAYMENT FOR SERVICES & SHARING OF HEALTH INFORMATION as explained in the accompanying Program Description. I have also received and agree with the Patient Consent for Use and Disclosure of Protected Health Information as explained in the Program Description. I have received the Notice of Privacy Practices.

Parent/Legal Guardian Signature DateParent/Legal Guardian’s Printed Name

Patient’s Signature (if 18 or older) DatePatient’s Printed Name

(Please continue to the next page)

Maysville School – Linked

Health CenterEnrollment Packet

To provide health services for your child we need the following information. If your children all have the same Parent/Legal guardian(s), you may complete this form one time only to be used for all of them.

Please list ALL Parent/Legal guardians:

Parent/Legal Guardian Name: Date of Birth: ______

Relationship to Child: Parent/Legal Guardian’s Social Security #:

Name/Relationship/DOB/SSN:

Address of Parent/Legal Guardian:

Home Phone: Cell Phone: Work Phone:

Emergency Contact: ______Phone Number:

Primary Care Provider: ______

Date of last complete yearly physical examination (head-to-toe):

Dentist: ______Phone Number:

Date of last routine dental check-up:

Eye Care Provider: ______Phone Number:

Date of last complete yearly optical examination:

Do you want a copy of the physical exam to go to your primary care provider?Yes No

Preferred Pharmacy: Phone Number:

Parent/Legal Guardian Signature: Date: ______

(Please continue to the next page)

HEALTH HISTORY FORM - Please complete, sign and return to the school office as soon as possible.

(If you need more space, please add to the back of the page)

PATIENT NAME:

Is your child allergic to any medications? No  Yes If yes, please list the medicines and reaction(s):

Please list any food or other allergies and your child’s reaction:

Does your child or any family member have or had any of these problems? (Please Check and describe what you know about it on the back of the page)

Child/FamilyChild/FamilyChild/Family

Asthma or wheezing______Fainting with exercise______Frequent nightmares______

Allergies/hay fever______Frequent headaches______Rheumatic fever______

ADHD/ADD______Frequent sore throats______Seizure disorder______

Anemia/blood problems______Frequent stomach aches______Sickle cell problems______

Anaphylactic reaction______High cholesterol______Sinus trouble______

Abnormal spinal curvature ______Heart murmur______Sleep problems______

Alcohol/Drug Abuse______Hearing loss/problems______Snoring______

Acne______Heart disease______Speech problems______

Behavior problems______High blood pressure______Stomach ulcers______

Boys: testicle not in sac______HIV/Aids______Suicidal thoughts______

Bowel movement in pants ______Hives______Stroke______

Bleeding Disorders______Hyperactivity______Teeth/dental problems______

Broken bones______Joint problems______Tuberculosis______

Cancer ______Kidney disease/problems______Underweight______

Chicken pox______Lead poisoning______Urinary tract infections______

Diarrhea/constipation______Learning problems______Eye lid twitching______

Chronic ear infections______Leukemia______Eye burning______

Concussion______Lumps in groin/breast______Double vision______

Depression______Mental illness______Dry eye______

Diabetes______Migraines______Eye strain______

Dizziness/Lightheaded______Muscle problems______Itchy eyes______

Eczema/skin infections______Nervous twitches/tics______Watery eyes______

Girls: vaginal discharge______Frequent nose bleed______Light sensitivity______

PATIENT NAME:

(If you need more space, please add to the back of the page)

Please circle yes or no below, and explain any yes answers on the line provided:

Does your child CURRENTLY take any medication(s)?YES NO

Has your child taken any medication(s) in the past?YES NO

Has your child ever been pregnant?YES NO How many living children has your child given birth to?

Has your child ever been in the hospital overnight?YES NO

Has the child had any surgery(ies)?YES NO

What surgery, date, and location.

Has your child had any head injury(ies)?YES NO

Does your child have any developmental delays?YES NO

What activities/hobbies does your student have:

Dental History

Please circle yes or no below, and explain any yes answers on the line provided:

Does your child have any dental pain?YES NO

Does your child brush their teeth?YES NO

Does your child floss? YES NO

Has your child received fluoride treatments?YES NO

Has anyone explained the importance of

primary teeth to your child?YES NO

Medical History

Please circle yes or no below, and explain any yes answers on the line provided:

Has a close relative had a heart attack before age 50?YES NO

Is there a gun in the home?YES NO

Does anyone at the child’s home smoke?YES NO

Has your child been the victim of abuse?YES NO

Has your child seen someone be abused?YES NO

Has your child been a victim of bullying? YES NO

PATIENT NAME:

School History

Please circle yes or no below, and explain any yes answers on the line provided:

Does your child have any learning problems?YES NO

Is your child in a special class (IEP)?YES NO

Has your child repeated a grade?YES NO

Does your child get into trouble often at school?YES NO

What are your child’s grades? Is this a change? Yes No

Vision History

Please circle yes or no below, and explain any yes answers on the line provided:

Does your child wear glasses currently?YESNOBROKEN/LOST

If yes:Full-TimeDistance OnlyReading

Does your child wear contact lenses currently?YESNO

If yes:Brand Solution: Optifree Renu Peroxide

Wearing:Remove NightlySleep In

Replacement:Monthly2 WeeksDaily

Has your child or any family members been diagnosed with/or had?

HISTORYEYESTUDENTFAMILY MEMBER (LIST RELATIONSHIP):

GlaucomaR L

CataractsR L

Eye InjuryR L

Eye PainR L

Lazy EyeR L

Retinal DetachmentR L

Macular DegenerationR L

DiabetesR L

Has you student had any of the following eye surgeries?

LASIKYESNO

CataractYESNO

Eye MuscleYESNO

Eye LidYESNO

Signature of Parent/Legal Guardian: Date:

Consent for Nitrous Oxide Sedation

If your child needs dental treatment, it may be beneficial or necessary to use nitrous oxide sedation to complete the dental treatment. Nitrous oxide relaxes children, makes them more comfortable, and gives them an all-around better experience at their dental appointment. By signing this form ahead of time, it will be easier for us to provide treatment in a more timely and efficient manner. We will attempt to call you prior to using nitrous oxide on your child. Please read the following and sign at the bottom if you consent to treatment with nitrous oxide sedation. It will only be used if necessary.

I give permission for a MVHC Dentist to give my child nitrous oxide sedation if indicated. I understand that some side effects could occur including:

Nausea and vomiting – we suggest that no food be eaten for at least two hours before the appointment.

Excessive sweating and patient may get red or flushed.

An unusually high amount of saliva is sometimes produced.

Although not common, a patient may get a sensation of having the chills.

In unusual circumstances, a child may become temporarily hyperactive.

The benefits include relaxation and possibly eliminating the need for local anesthesia injections(“Novocain”).
For those patients who may need both, the use of nitrous oxide/oxygen will make the injections mush easier for the patient.

At no time will the patient be “asleep” and at all times the patient will be given more oxygen than what is present in the air. Patients will be monitored continually by the dentist and staff, and a parent can be present as well if requested.

If you would like to be present, please make a note on the top of this form and we will be happy to schedule an appointment for you at your convenience.

 I consent for my child to receive nitrous oxide sedation as deemed necessary by the dentist. I understand the dental staff will attempt to contact me prior to administering nitrous oxide.

 I do not consent for my child to receive nitrous oxide sedation.

Patient Name

Signature (Parent/Legal Guardian)Phone NumberDate

MUSKINGUM VALLEY HEALTH CENTERS (MVHC)

PATIENT REGISTRATION FORM

PATIENT INFORMATION:
Last Name / First Name / MI / Nickname / Social Security # / Birth Date / Sex
Last Name / First Name / MI / Nickname / Social Security # / Birth Date / Sex
Last Name / First Name / MI / Nickname / Social Security # / Birth Date / Sex
Last Name / First Name / MI / Nickname / Social Security # / Birth Date / Sex
Patient Billing Address (Parent/Legal Guardian) / City / State / Zip
Patient Residence (if different) / City / State / Zip
RESPONSIBLE PARTY (Required for patients under age 18 and whenever the guarantor is not the patient):
Last Name / First Name / MI / Social Security # / Birth Date / Relationship
INSURANCE INFORMATION (Please present ALL insurance cards and a picture ID to the receptionist):
Primary Insurance / Policy # / Group # / Effective / Co-Pay / Policy Holder / Relationship
STATISTICS REQUIRED FOR GOVERNMENTAL REPORTING:
Please √ Race:  White  Black/African-American  American Indian  Asian  Hawaiian
 Pacific Island  More than one race  Other
Please √ Ethnicity:  Hispanic or Latino  Not Hispanic or Latino  Unknown/Not Reported
Please √ to indicate the languages you can speak fluently:
 English  Spanish  French  German  Russian  Other:
Do you speak English fluently?  Yes  No If no, preferred language: ______
Please √ all that apply:  Visually impaired  Hearing Impaired
 Language Barrier  Veteran  Smoker  Homeless  Migrant Farm Worker
Please √ you Religion:  Christian  Agnostic  Atheist  Buddhist  Jewish
 Hindu  Islamic  Pentecostal  Scientologist  Other
Please √ Tax Filing Status:  Returned Not Filed  Single  Married  Head of Household
If you √ Head of Household, please indicate if the Head of Household is a:  Male  Female
Please √ Marital Status:  Single  Married  Widowed  Legally Separated
 Divorced  Life Partner  Other
Please √ Student Status:  Full-time student  Part-time student
CONTACT PREFERENCES:
√ to indicate the method of contact preferred:  Home ( ) ______ Day/Work ( ) ______
 Cell/Alternate ( ) ______ E-mail ______
Emergency contact name and numbers
ADVANCED DIRECTIVE:
Do you have a living will?  Yes  No If YES, at which hospital is if filed? ______

MUSKINGUM VALLEY HEALTH CENTERS (MVHC)

We are required to give each patient a copy of our Notice of Privacy Practices which states how we may use and/or disclose your health information. Bu signing this form you acknowledge receipt of this notice and a copy of our patient brochure. You may refuse to sign if you wish.

Please answer the following questions so that we can contact you in the most efficient way possible.

If you have an answering machine at home, may we leave a message?YesNo

May we leave a message at your work for you to call out office?YesNo

May we e-mail you?YesNo

Is there a person at you house that we may leave a message with?YesNo

List below any person/persons authorized by you to discuss/receive your medical information:

Name/Address/Phone/Relationship

******************************************************************************************

Employer (Name, Address, Phone Number):

Do you live in public housing?  Yes No

Household Members:

Name / Date of Birth / Relationship / Income / Hr/Wk/Bi-Wk/Mo

Because we receive some funds to help us offer to the uninsured, we are asked to keep track of the income of all our patients. We also offer a sliding fee scale for people with no insurance, and we need this information to calculate their discount. ALL INFORMATION WILL BE KEPT CONFIDENTIAL.

Income Before Taxes / Hr/Wk/Bi-Wk/Mo / Other Income / Documented
$ per
Family Size

I certify that all information given by me is true. I consent to any services rendered to me or my dependents by the attending provider/physician. I understand this authorization will also permit the center to release information related to my medical records to other offices to assist in my continuing care. I acknowledge full financial responsibility for services rendered by Muskingum Valley Health Centers. I authorize the release of information to my insurance carrier and authorize payment directly to Muskingum Valley Health Centers. I have read and fully understand the above.

Signature:Date:

( ) Patient ( ) Parent ( ) Legal Guardian

Print Name and Address:

Witness: Date:

THE FOLLOWING PAGES

ARE FOR YOU TO REVIEW

AND KEEP FOR YOUR

RECORDS

Program Description

Maysville School – Linked Health Center (SLHC)

Welcome to Muskingum Valley Health Centers’ (MVHC) School-Linked Health Center (SLHC). The SLHC makes medical, dental, and vision care available to students when needed. If your child/adolescent becomes sick at school or if your child adolescent needs a check-up, sports physical, immunizations, routine dental care, or a vision exam they can have it done at the SLHC. If your child/adolescent develops a dental problem at school, a dentist can see your child without having to take time away from work and minimize the time that your child is out of the learning environment.

How the SLHC Works:

You must complete the attached consent form and the other information pages and return it to the school nurse or school office.
You or your child may schedule an appointment in the SLHC if your child is sick or injured. You can also schedule an appointment for physicals, immunizations, required sports or employment physicals, dental care, eye exams, and all associated healthcare concerns. Any necessary prescriptions will be provided.
After your child’s visit with the provider, dentist, or optometrist attempts will be made to contact you as necessary.
The SLHC does not take the place of your primary care provider (PCP) and joining the program does not mean that you are changing your child’s PCP.You will be encouraged to have any needed follow-up care with that PCP and a summary of your child’s visit at the SLHC will be sent to that office. However, if you do not have a regular PCP, we welcome the opportunity to become your child’s PCP. If your child is already a patient at any of MVHC’s locations, you still must sign this consent to be a part of the SLHC.

Patient Rights and Responsibilities:

Respectful and equal treatment, care, and accommodations are available regardless of race, age, ethnicity, creed, sex or sexual orientation.
To have a healthcare assessment and plan of care and participate in your healthcare plan.
To talk to your healthcare provider openly and privately.
It is the patient’s responsibility to carry out the recommended treatment plan.
Allow at least 30 days for completion of insurance or disability forms and transfer of treatment records.
Notify the SLHC if you have received treatment in an Emergency Room or hospital.
After hours, in case of emergency call 911 or go to the nearest emergency room. If you have an urgent issue and would like to speak with a nurse, please contact the NurseLine at (740) 455-4949.

The Healthcare Services we may provide include:

Ill visits (for example: sore throat, rash, asthma attack, etc.) and follow-up for medical problems, including physical examination, tests and treatment/medications as needed.
Minor injury evaluation, including first aid.
Routine physical examination (including sports and work physicals) with immunizations, routine tests, and treatments as needed.
Management of chronic conditions such as hypertension, diabetes, and high cholesterol.
Health education and wellness promotion
Referral to outside agencies for further care that cannot be provided at the SLHC.

The Dental Services we may provide include:

Routine dental examination and screenings, including dental health education and preventive services such as cleaning and dental sealants to help stop tooth decay.
Problem visits (for example, for pain, infection or injury) or visits for urgent or emergency care, to include examination,

x-rays, fillings, extractions (the pulling of loose or infected teeth), necessary treatment (including medication) for oral infection or other problems, and/or other procedures (including root canals on front teeth).